Sample Benefit Enrollment Guide

2019 Benefit Guide

Company Name

Company Name

Benefits Enrollment Welcome!

Company Name is bringing you this Benefits Guidebook as a quick reference tool for your medical and ancillary

insurance questions. We encourage you to share this guidebook with your family members to help gain a better, overall

understanding of the benefits available to you. Salaried employees working 30+ hours per week are eligible for benefits.

You are only able to join or make changes to your benefit elections during Open Enrollment or due to a qualifying life event, see below for examples. You have 30 days from those events to update your benefit elections. Otherwise, you will not be able to enroll until the next open enrollment period.

Examples of a qualifying life event include but are not limited to the following:

„ „ Birth, legal adoption, or placement for adoption. „ „ Marriage, divorce, or legal separation. „ „ Dependent child reaches age 26. „ „ Spouse gains or loses employment or eligibility with current employer. „ „ Death of spouse or dependent child.

„ „ Spouse or dependent becomes eligible or ineligible for Medicare/Medicaid or SCHIP. „ „ Change in residence that changes eligibility for coverage. „ „ Court-ordered change.

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2019 Benefit Guide

At Company Name, nothing is more important than your overall sense of well‑being. Our comprehensive suite of benefits

supports every aspect of your health and wellness, and we urge you to take advantage of the broad range of available

features.

Read on for all the details you need to make your benefits selections.

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Company Name

Eligibility

Employees working 30+ hours per week are eligible for benefits.

Please carefully review the information contained in this Guidebook.

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2019 Benefit Guide

Medical Benefits

Company Name is committed to providing quality health coverage to you and your dependents. The following medical plan options are available in 2019:

„ „ HSA Plan „ „ PPO Plan

Terms You Need to Know

PPO: Preferred Provider Organization

Copay: A copay is a fixed out-of-pocket amount paid by an insured individual for covered services (one-time payment per visit/service/Rx cost).

EPO: Exclusive Provider Organization; in-network only

Deductible: The amount you pay for covered health care services before your insurance plan starts to pay (one amount per calendar year—not per incident or service).

HDHP: High Deductible Health Plan

HSA: Health Savings Account

Coinsurance: Percent of expenses patient is responsible for paying after deductible

EOB: Explanation of Benefits

Out-of-Pocket Maximum: Most one will pay for covered services during a policy year

Premium: Cost to purchase insurance coverage.

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Company Name

Medical Plan Summary

Medical Plan Designs

HSA PPO

PPO Plan

In Network Benefits

Funding of HSA

$X

$X

Deductible

$X

$X

Insurance coverage when deductible is reached (coinsurance)

$X

$X

Your cost for primary Dr.

$X

$X

Your cost for specialist

$X

$X

Emergency/Urgent Care

$X

$X

Inpatient Hospital

$X

$X

Preventive Care

$X

$X

Out-of-Pocket Maximum

$X

$X

Out of Network Benefits

Deductible

$X

$X

Coinsurance

$X

$X

Out-of-Pocket

$X

$X

* NOTE: The full cost of what you pay a provider may not necessarily be credited/counted towards your out-of-network deductible. The insurance company will only count the cost deemed reasonable and customary by them for that service.

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2019 Benefit Guide

Medical Premiums

Benefit Plan

Coverage Level

Per Paycheck (Semi-Monthly)

HSA Plan

Employee Only Employee + Spouse/Partner

Employee + Children Employee + Family

PPO Plan

Employee Only Employee + Spouse/Partner

Employee + Children Employee + Family

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Company Name

Prescription Drug Benefits

When you select a medical plan with Aetna, you automatically receive the corresponding prescription drug plan shown below. These

prescriptions are administered by RxBenefits in partnership with Optum. The RxBenefits model provides an effective, complete

pharmacy benefit management solution, with industry-leading support.

Questions? Contact RxAssure, our member service team at 800.334.8134 or RxHelp@rxbenefits.com .

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2019 Benefit Guide

RxBenefits Prescription Drug Plan Summary

Plan Design

HSA PPO

Standard PPO

Retail (31 day supply)

$X

$X

Mail Order (90 day supply)

$X

$X

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Company Name Aetna Concierge Have questions about your Medical Plan? Aetna Concierge can assist you with: „ „ A question about a diagnosis „ „ Selecting a doctor

„ „ Learning about your coverage „ „ Planning for upcoming treatment

Think of Aetna Concierge as your personal assistant for healthcare.

Aetna Concierge will: „ „ Find solutions that fit your needs „ „ Show you how to use our online tools to make the decisions that are right for you „ „ Find network providers based on your medical needs „ „ Even assist you in scheduling appointments

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2019 Benefit Guide

AETNA CONCIERGE IS AVAILABLE MONDAY–FRIDAY FROM 8 A.M. TO 6 P.M. (local time)

Connect with Aetna Concierge Call 855-708-6251 (also conveniently listed on your Aetna member ID card).

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Company Name Teladoc: Virtual Visits

Virtual visits are typically less expensive than office visits, urgent care and the emergency room. Doctors can answer questions,

diagnose illnesses, provide referrals and write prescriptions.

Conditions commonly treated through Virtual Visits:

„ „ Bladder infection/UTI „ „ Bronchitis „ „ Cold/Flu „ „ Upper Respiratory

„ „ Pink Eye „ „ Rash „ „ Sinus Infection „ „ Migraine/Headache

Download the Teledoc App Today! Access Teledoc services 24/7/365 by mobile app, online video or telephone.

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2019 Benefit Guide

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Company Name Flexible Spending Accounts (FSA)

A great way to plan ahead and save money each year is to participate in the flexible spending account (FSA) benefit, provided by BRI. To

take advantage of an FSA, you must re-enroll in the plan each year .

FSAs allow you to redirect a portion of your salary on a pre-tax basis into reimbursement accounts.

Money from these accounts may be used to pay medical, dental, vision, dependent care, or transit

expenses that you had to pay out-of-pocket for.

Pre-tax means that a designated portion of your salary are not subject to Social Security tax, federal

income tax, and in most cases, state and local income taxes.

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2019 Benefit Guide

Remember: Use It or Lose It Healthcare and dependent care funds do not rollover to the next plan year.

services must be necessary to allow you to work or attend school

Healthcare FSA HSAPPO members are not eligible.

full-time. Dependent care expenses are reimbursable as long as

the provider is not your dependent for income tax purposes. To

You may participate in this FSA if you are not contributing to a

be reimbursed, you will be asked to provide the Tax ID of the

Health Savings Account (HSA).

provider when submitting receipts.

You may contribute up to $2,700 per year to your Healthcare

Commuter FSA Everyone is eligible regardless of medical plan.

FSA. These dollars can only be used on eligible healthcare

expenses. A complete list of eligible expenses can be found on

irs.gov under the IRS Publication 502.

You can contribute a portion of your salary on a pre-tax basis to

pay for eligible expenses such as transit passes, vanpooling and

Dependent Care FSA Everyone is eligible regardless of medical plan.

parking.

„ „ Public Transit: $265/month „ „ Parking: $265/month

You may contribute up to $5,000 per year or $2,500 per year if

you are married and file separate tax returns. Eligible dependents

include children younger than 13 and dependents of any age

who are unable to care for themselves due to a disability. The

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Company Name PayFlex ® Health Savings Account (HSA)

Enrolling in an HSA, like FSAs, will reduce your taxable income. You may use your HSA funds to pay for eligible healthcare expenses for

you and your tax dependents.

HSAs Offer You the Following Advantages: „ „ Tax savings: Interest accumulates tax-free and funds are withdrawn tax-free when paying for eligible expenses. „ „ Reduced out-of-pocket costs: Reduced out-of-pocket costs: You can use your HSA funds to help you satisfy your health plans’ annual deductible. „ „ A long-term investment that stays with you: Unused account dollars are yours to keep even if you retire or leave the company. Additionally, you can invest your HSA funds so your available healthcare dollars can grow over time. „ „ The opportunity for long-term savings: Any unused HSA funds will accumulate year after year and can be used to reduce future out-of-pocket healthcare expenses (even after retirement).

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2019 Benefit Guide

You are eligible to open and fund an HSA if:

„ „ You are enrolled in an HSA-eligible High Deductible Health Plan, such as the HSA PPO Plan. „ „ You are not covered by your spouse’s health plan (unless it is a qualified HDHP) or flexible spending account (FSA). „ „ You are not eligible to be claimed as a dependent on someone else’s tax return. „ „ You are not enrolled in Medicare, TRICARE, or TRICARE for Life. „ „ You have not received Veterans Administration benefits in the past three months. How Much can be Deposited

On the PayFlex Employee Portal or Mobile App You Can: „ „ Check your balance and view alerts „ „ Make payments, withdrawals, and deposits „ „ View PayFlex debit card transactions „ „ View common eligible expense items and more

into an HSA in 2019? „ „ Under age 55 (and not enrolled in Medicare): z z Up to $3,500 for individual coverage z z Up to $7,000 for family coverage „ „ Age 55 or older (and not enrolled in Medicare): z z Catch-up contribution is an additional $1,000

z z Up to $4,500 for individual coverage z z Up to $8,000 for family coverage Pay the PayFlex Way Once funds are available in your HSA, PayFlex makes it easy to pay for your eligible expenses.

„ „ Use the PayFlex Card®, your account debit card: When you use the PayFlex debit card, your expense is automatically paid from your account. „ „ Pay yourself back: If you paid out-of-pocket for any eligible expense, you can withdraw the funds from your HSA to pay yourself back via direct deposit or check (with a copy of the receipt or invoice).

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Company Name Dental Plans

Company Name provides dental plans through MetLife. To access Metlife’s provider directory, please visit metlife.com/dental .

Your plan will be listed under “Company Name.” On the website, you can also: see your claims, estimate procedure costs and

find a dentist.

NOTE: Metlife does not issue ID Cards. Your provider can use your Social Security Number to look up your coverage information.

MetLife Dental Premiums

Benefit Plan

Coverage Level

Per Paycheck (Semi-Monthly)

Basic Plan

Employee Only Employee + Spouse/Partner

Employee + Children Employee + Family

Buy-Up Plan

Employee Only Employee + Spouse/Partner

Employee + Children Employee + Family

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2019 Benefit Guide

MetLife Dental Plan Summary

Basic Plan

Buy Up Plan

Benefit Summary

In-Network Non-Network * In-Network Non-Network *

Calendar Yr. Deductible (Types B-C)

$100 ind/$300 fam

$50 ind/$150 fam

Calendar Yr. Maximum Benefit (per person)

$1,000

$1,500

Type A: Diagnostic & Preventive

Cleanings (2 per 12 months)

Oral Exams (2 per 12 months) Fluoride (2 per year children under 19)

100%

100%

100%

100%

X-rays (frequency variations) Sealants (for children under 19)

Type B: Basic Restorative

Fillings, Simple Extractions

Space Maintainers Periodontal Scaling Non-Surgical Endo and Perio

80%

50%

100%

80%

Type C: Major Restorative

Oral surgery, Anesthesia

50%

50%

60%

50%

Access MetLife online or via mobile app to: „ „ View your claims „ „ View your ID Card „ „ Look up providers

Surgical Endo and Perio Root Canal Therapy Dentures, Crowns, Bridges Bridge Repairs, Implants

Type D: Orthodontia (for children under 19)

50%

50%

50%

50%

Orthodontia lifetime max

$1,000

$1,000

* Services with Non MetLife dentists are paid at the rate of reasonable and customary.

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Company Name Vision Plan

Your VSP Network is the Choice Plan Network. Visit the VSP website at vsp.com to find a complete listing of participating providers.

NOTE: VSP does not issue ID Cards. Your provider can use your Social Security Number to look up your coverage information.

When you need services, consider using an in-network provider for the maximum level of coverage for your vision benefits.

In-Network (You Pay)

Out-of-Network (You Pay)

Eye Exam

Frames

Standard Plastic Lenses

Single Vision Bifocal Trifocal

Contact Lenses* (Including fit, follow-up and materials; in place of standard lenses):

Copay Allowance Wholesale/Retail

Vision Correction Procedures

Lasik

Frequencies

Exams, Lenses and Contacts Frames

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2019 Benefit Guide

Extra Savings and Discounts!

VSP members also get extra savings and discounts on all types of purchases such as:

Access VSP online or via mobile app to: „ „ Review your benefits „ „ Track your claims „ „ Find a provider

„ „ Additional savings on featured frame brands „ „ Free trials on popular contact lens brands „ „ LASIK

You can find more information when logging into your VSP account online.

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Company Name Health Advocate

Insurance can be confusing and when things get tricky, Health Advocate is there to help.

Employees and their family members can call and get help with many health insurance related concerns, including:

„ „ Finding a provider and getting an appointment scheduled, „ „ Resolving and navigating claim issues, „ „ Finding Medicare options for parents and much more!

For More Info: Call (866) 695-8622 or visit members.healthadvocate.com .

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2019 Benefit Guide

Short and Long Term Disability Plans

The Company pays for your Short Term Disability (STD) and Long Term Disability (LTD) benefits in full. STD and LTD are designed to

replace a portion of your income for a non-work-related injury or illness..

If you are unable to return to work at the end of your STD period, you may apply for LTD. You will be requested to provide

documentation when applying for both of these benefits.

Benefit

Who Pays

How Much Coverage?

Effective 1st of month following your date of hire. 60% to $1,500 weekly max Beginning on the 8th day of being unable to work. 13 week max Effective 1st of month following your date of hire. 60% (up to $15,000 monthly max), beginning on the 91st day of being unable to work.

Short Term Disability

Company

Long Term Disability

Company

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Company Name Life and Accidental Death & Dismemberment (AD&D) Insurance

Important: Name a Beneficiary!

Company Name’s comprehensive benefits package through

Aetna includes financial protection for you and your family in

the event of an accident or death. Basic life coverage is provided

The beneficiary is the person who will receive the insurance

automatically at no cost to you upon employment .

benefit in the event the insured passes away.

Benefit

Who Pays

How Much Coverage

Beneficiaries can use the money for:

Life and AD&D Insurance

Employer Pays Employer Pays

„ „ Making up for your lost income „ „ Funding a child’s education „ „ Paying off household debt „ „ Paying for your funeral and other related expenses

*Subject to IRS tax on employer sponsored Life Insurance plans in excess of $50,000.

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2019 Benefit Guide

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Company Name Travel Assistance Program „ „ Covers employees whether on a business or personal travel. „ „ The services are offered by AXA Assistance USA, Inc. „ „ 24/7 travel services and support z z Emergency medical services z z Emergency medical evacuation services z z Medical return to country z z Return of dependent children z z Vehicle return services Health insurance coverage when traveling.

z z Dispatch of physician z z Replacement of prescription medication z z Lost document and article assistance z z Emergency cash and bail assistance

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2019 Benefit Guide

Employee Assistance Program (EAP)

We all know that life can be challenging at times. Issues like illness, debt and family problems can leave us feeling worried and not able

to perform our best. The EAP, sponsored by Aetna, provides confidential support and resources for you and your dependents at no

charge. You can seek expert guidance on all kinds of issues such as daily stress, mental health & well-being, personal & professional

relationships, and substance abuse.

Here’s what the program offers:

„ „ Unlimited telephonic consultation with an EAP Counselor. „ „ Your EAP consultations are completely confidential. „ „ Referrals to local counselors – up to three face-to-face sessions free of charge. „ „ Online portal featuring free webinars, a concierge database, discount programs and more!

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Company Name Aetna Accident and Critical Illness

Company Name offers supplemental Accident and Critical Illness through Aetna. Accident and

Critical Illness coverage provides financial protection for you and your family if the unexpected

occurs.

Accident

You will receive a cash benefit based on the type of injury you sustain or the type of treatment

you need. Examples of covered injuries and expenses include:

Initial Care

Benefit Amount

Surgical Care

Benefit Amount

Torn Knee Cartilage

$750

$150 (3 visits per plan year) $150 (3 visits per plan year)

Initial Treatment—ER

Ruptured Disc

$750

Medical Imaging (MRI, CT Scan, etc.)

Fracture, Dislocation & Other Injury

Benefit Amount

Hospital Care

Benefit Amount

Inpatient Stay—Initial Day Inpatient Hospital Daily Benefit

Dislocation Benefit: Hip—Closed Fracture Benefit: Clavicle—Closed Burn—3rd Degree (>10%)

$1,000

$3,000

$200

$600

$18,000

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2019 Benefit Guide

Critical Illness

You will receive a cash benefit upon diagnosis of a critical illness. Unlike your medical plan, this plan pays benefits directly to the

covered employee or their family member. In addition, you will receive a $50 Health Screening Benefit when you, your spouse or

children go to the doctor for a wellness checkup.

Coverage

Face Amount

Cancer Benefit

Benefit Amount

Employee

$10,000

Cancer (Invasive)

100%

Spouse/Child(ren)

$5,000

$1,000 (once per lifetime)

Skin Cancer

Covered at 100% Heart Attack

Covered at 25% Alzheimer’s Disease Lupus Muscular Dystrophy Parkinson’s Disease Multiple Sclerosis

Subsequent Diagnosis

Benefit Amount

Employee

100% after 180 days

Stroke Coma End Stage Rental Disease Paralysis

Spouse

50% after 180 days

Child(ren)

25% after 180 days

Note: See Benefit Summary for a complete list of benefits.

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Company Name

Contacts

Vision - VSP

Medical - Aetna

Phone:

(800) 877-7195

Phone:

(855) 708-6251

Website:

vsp.com

Website:

aetna.com

Life - Aetna

Prescription Drug - RxBenefits Phone:

Phone:

(888) 772-9682

(800) 334-8134

Website:

aetna.com

Email:

RxHelp@rxbenefits.com

Disability - Aetna

Health Savings Account - PayFlex Phone:

Phone:

(877) 232-0466

(844) 729-3539

Website:

aetnadisability.com

Website:

payflex.com

Accident and Critical Illness Phone:

Health Advocate

(888) 357-9089

Phone:

(866) 695-8622

Website:

memberbenefitlogin.com

Website:

healthadvocate.com/members

Travel Assistance - Aetna - AXA Assistance Phone (Inside the US):

(877) 935-3704 (312) 935-3704

Teladoc

Phone (Outside the US):

Phone:

(855) 835-2362

Website:

aetnatravelassistance.com

Website:

teladoc.com/Aetna

Employee Assistance Program - Aetna Phone:

Flexible Spending Accounts - BRI Phone:

(855) 283-1915 mylifevalues.com

(800) 473-9595

Website:

Website:

benefitresource.com

Dental - MetLife

Phone:

(800) 275-4638

Website:

metlife.com/mybenefits

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2019 Benefit Guide

Ready to enroll in your benefits? Click “Enroll Now”!

Questions? Email _______________________ .

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The descriptions of the benefits are not guarantees of current or future employment or benefits. If there is any conflict between this guide and the official plan documents, the official documents will govern.

2019 Benefit Guide